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JC Alert-Credentialing and Privileging - Requirements for Physician Assistants and Advanced Practice Registered Nurses

Medical Staff (MS) (Hospital and Hospital Clinics / Hospitals)

Credentialing and Privileging - Requirements for Physician Assistants and Advanced Practice Registered Nurses

Modify | May 12, 2017

Since Physician Assistants (PA) and Advanced Practice Registered Nurses (APRN) are not physicians, are organizations required to credential and privilege them via the requirements found in the Medical Staff (MS) chapter of the accreditation manual?

Yes, any provider recognized by state law – and providing services as a ‘Licensed Independent Practitioner (LIP)’** are required to be granted privileges prior to providing such care, treatment or services. While Physician Assistants (PA) are generally not recognized by law/regulation as ‘independent practitioners’, they are subject to the same credentialing and privileging requirements (see MS.06.01.01 - MS.06.01.09). 
Examples of Care, Treatment or Services subject to the Medical Staff requirements may include, but are not limited to:

  • Writing orders for medications, tests, and procedures
    • Interpreting tests and treatments
    • Performing history and physicals
    • Wound debridement
    • Central line insertions
    • Assisting with interventional or surgical procedures

The requirements for conducting a Focused Professional Practice Evaluation (FPPE - MS.08.01.01) and an Ongoing Professional Practice Evaluation (OPPE - MS.08.01.03) also apply to these practitioners.
When an APRN or PA functions in a limited role, such as an educator, and not directing care as an independent practitioner, the Medical Staff requirements would not apply.

Additional Resources:
Click here to return to the list of FAQs available on our website.
The Leading Practice Library (available only to Joint Commission-accredited organizations via their secure Extranet site).

** It is the responsibility of the individual organization to determine, based on law/regulation, if the APRN or PA meet the following definition of a Licensed Independent Practitioner:  “An individual permitted by law and by the organization to provide care, treatment, and services without direction or supervision. A licensed independent practitioner operates within the scope of his or her license, consistent with individually granted clinical privileges. When standards reference the term licensed independent practitioner, this language is not to be construed to limit the authority of a licensed independent practitioner to delegate tasks to other qualified health care personnel (for example, physician assistants and advanced practice registered nurses) to the extent authorized by state law or a state's regulatory mechanism or federal guidelines and organizational policy.”